Predicted Coronary Occlusion and Impella Salvage During Valve-in-Valve Transcatheter Aortic Valve Replacement.

We describe an interesting case of a 71 years old fragile female, with progressive shortness of breath on exertion and ankle swelling, cardiac failure NYHA class III. She also had chest irradiation due to Hodgkin's disease many years before, previous surgical aortic valve replacement using bioprosthetic stent-less Freestyle #25 mm valve (Medtronic, Inc) in 2000 for severe aortic stenosis, history of cardiac arrest in 2012 and angioplasty to ostial RCA, PCI to ostial RCA in 2014, CABG (RA graft to RCA) in 2014 (RCA intra-stent restenosis with refractory ischemia), anemia requiring regular transfusions, bronchiectasis and chronic kidney disease. Because of the great comorbidities, STS 4.9% and worsening of the symptoms due to severe aortic valve regurgitation, heart team decided to perform "valve-in-valve" Transcatheter Aortic Valve Replacement (VIV-TAVR), but we already predicted coronary occlusion while performing this procedure because of the low left main coronary ostium and short aortic valve sinus. So regarding the probable left main coronary occlusion during the valve implantation, we decided to perform the placement of a not deployed stent inside the left main prior to the valve procedure, and to deploy it in case the predicted left main occlusion occurred. So just after the VIV-TAVR procedure, we observed left main coronary occlusion and the patient got ischemic cardiogenic shock and cardiac arrest, so we performed immediate PCI and deployed the bailout stent. After some minutes of chest compressions, an Impella mechanical circulatory support system (Abiomed, Danvers, MA) had to be installed. Patient recovered spontaneous circulation, and after hemodynamic stabilization, she was sent to the Intensive Coronary Unit, without further complications. She was discharged successfully without neurological or cardiac sequelae after 1 week.

Rotational Atherectomy and Mechanical Support to Treat Left Main.

We describe a complex percutaneous coronary intervention using rotational atherectomy (Rotablator, Boston Scientific, Marlborough, Massachusetts) and mechanical circulatory support (Impella, Abiomed, Danvers, Massachusetts) in a patient with multiple comorbidities scheduled to undergo a left main coronary percutaneous coronary intervention using a 2-stent technique based on angiography. However, intracoronary optical coherence tomography changed our strategy to a successful single-stent procedure. (Level of Difficulty: Advanced.).

Vascular response and healing profile of everolimus-eluting bioresorbable vascular scaffolds for percutaneous treatment of chronic total coronary occlusions: A one-year optical coherence tomography analysis from the GHOST-CTO registry.

BACKGROUND: Bioresorbable vascular scaffolds (BVS) have been heralded with potential benefits that are especially desired in long lesions, including chronic total occlusions (CTOs). Procedural feasibility and mid-term outcomes of BVS in CTOs have been reported. However, there is still a paucity of data regarding the vascular and healing response to BVS in CTOs evaluated by optical coherence tomography (OCT). METHODS: This study included prospectively 21 patients who had a CTO lesion treated with a BVS. Angiography and OCT scan were recorded at either post-implantation and 1-year follow-up. Quantitative coronary angiography and OCT analyses were performed by an independent core laboratory. RESULTS: The angiographic analysis showed a significant increase in the percentage of in-segment diameter stenosis at 1year (11.89±9.5% vs. 21.84±11.7%; p=0.002). The OCT analysis showed a trend (p=0.07) towards increased mean scaffold area and significant reductions in mean lumen diameter (3.1±0.36mm vs. 2.85±0.47mm; p=0.0046), mean lumen area (7.8±1.73mm2 vs. 6.76±2mm2; p=0.0082) and minimal lumen area (5.26±1.86mm2 vs. 3.56±1.52mm2; p<0.0001). Malapposition area and volume decreased from 0.26±0.17mm2 to 0.08±0.1mm2 (p=0.0003) and from 14.17±12.92mm3 to 3.99±4.46mm3 (p=0.0014), respectively. The rate of uncovered or malapposed struts, measured at the frame level, was 5.29±6.48% at 1year. CONCLUSIONS: In a small series of CTO patients treated with BVS implantation, OCT outcomes at 1year displayed an overall favorable vascular response and healing profile.

Impact of Neointimal Calcifications on Acute Stent Performance during the Treatment of In-Stent Restenosis.

Optical coherence tomography (OCT) has become the invasive imaging modality of choice for coronary stent assessment due to its unmatched spatial resolution. Neointimal calcification (NC) is a rare finding, observed in 5-10% of in-stent restenosis (ISR) neointima. The impact of NC on percutaneous coronary intervention of ISR is unknown. We therefore present the outcome of six unique cases of ISR and NC in which OCT was used to evaluate the impact of NC on the quality of stent-in-stent deployment for the treatment of ISR. This series demonstrates for the first time the impact of NC on stent expansion, a finding which might help guiding percutaneous coronary intervention for ISR with NC.

Optical coherence tomography of the intracranial vasculature and Wingspan stent in a patient.

A 67-year-old man with medically refractory vertebrobasilar insufficiency and short segment occlusions of the intracranial vertebral arteries was treated with angioplasty and stent placement. Fifteen hours after the procedure the patient developed symptoms of posterior fossa ischemia and repeat angiography showed thrombus formation within the stent which was treated with thrombolytic and aggressive antiplatelet therapy. Angiography revealed lysis of the clot, but concerns regarding the mechanism of the thrombotic phenomenon prompted frequency-domain optical coherence tomography (FDOCT) assessment. FDOCT provided excellent visualization of the stent and vessel wall interactions, as well as excluding residual flow-limiting stenosis, obviating the need for further intervention. The potential utility of FDOCT in the evaluation of intracranial atherosclerotic disease and additional intracranial applications are discussed.

Optical coherence tomography of the intracranial vasculature and Wingspan stent in a patient.

A 67-year-old man with medically refractory vertebrobasilar insufficiency and short segment occlusions of the intracranial vertebral arteries was treated with angioplasty and stent placement. Fifteen hours after the procedure the patient developed symptoms of posterior fossa ischemia and repeat angiography showed thrombus formation within the stent which was treated with thrombolytic and aggressive antiplatelet therapy. Angiography revealed lysis of the clot, but concerns regarding the mechanism of the thrombotic phenomenon prompted frequency-domain optical coherence tomography (FDOCT) assessment. FDOCT provided excellent visualization of the stent and vessel wall interactions, as well as excluding residual flow-limiting stenosis, obviating the need for further intervention. The potential utility of FDOCT in the evaluation of intracranial atherosclerotic disease and additional intracranial applications are discussed.

Assessment of coronary stent by optical coherence tomography, methodology and definitions.

Optical coherence tomography has emerged as a powerful tool for stent assessment, and in a short time, has become the modality of choice for studying stent and vascular interactions in vivo. In this review, we discuss qualitative and quantitative parameters used for stent assessment by OCT. Various qualitative/quantitative variables of stent assessment are discussed in the perspective of the clinical and research values of each of them.

Aspectos contemporâneos da intervenção coronária percutânea no tratamento eletivo de estenoses localizadas no tronco não-protegido da artéria coronária esquerda / Contemporary review of elective percutaneous coronary intervention for non-protected left main coronary artery disease

A intervenção coronária percutânea (ICP) em tronco da artéria coronária esquerda (TCE) não-protegido era considerada até bem pouco tempo uma terapia proscrita em indivíduos elegíveis à revascularização cirúrgica convencional (RM), padrão de referência no tratamento dessa enfermidade. Esse conceito foi embasado nas elevadas taxas de eventos cardíacos adversos maiores em pacientes tratados com ICP com balão e, posteriormente, em pacientes tratados com stents não-farmacológicos. Mais recentemente, a introdução dos stents farmacológicos em nossa prática clínica diária promoveu redução substancial das taxas de reestenose e eventos cardíacos adversos maiores em pacientes tratados percutaneamente. Os bons resultados obtidos motivaram revisões das principais diretrizes, que passaram a considerar esse tratamento uma opção viável, variando seu nível de indicação conforme a complexidade clínica, bem como a anatomia coronária a ser abordada. Contudo, apesar desse importante avanço, alguns pontos devem ser destacados: a abordagem da bifurcação distal está associada a pior evolução em comparação ao tratamento do óstio ou corpo, sendo a técnica do T provisional a mais indicada nessa situação. Não foram estabelecidas, até o momento, diferenças substanciais nos desfechos entre os distintos stents farmacológicos, e seu implante, auxiliando por métodos de imagem intravasculares, deve ser incentivado. Finalmente, a avaliação e a seleção dos pacientes para o procedimento devem ser orientadas por meio de escores que avaliem características clínicas e angiográficas.

Percutaneous coronary intervention (PCI) in the non-protected left main coronary artery (LM) was until recently considered a harmful practice for individuals eligible for coronary artery bypass grafting (CABG), a gold standard in the treatment of this disease. This concept was based on the high rates of major adverse cardiac events in patients treated with balloon angioplasty and later on, in patients treated with bare-metal stents. More recently, the introduction of drug-eluting stents in our daily clinical practice promoted marked reductions in the rates of restenosis and major adverse cardiac events in patients treated by PCI. The good results obtained led to a review of the PCI guidelines, which now consider this treatment as a feasible option, classifying the level of indication according to clinical complexity as well as the coronary anatomy to be approached. However, despite this significant advance, it is important to highlight some aspects: treatment of the distal bifurcation is associated to a worse prognosis than ostial or midshaft lesions and the best approach in this situation seems to be the T-provisional technique. So far, substantial differences have not been established for different drug-eluting stents and intravascular imaging techniques should be strongly encouraged to guide their implant. Finally, patient assessment and selection for the procedure should be guided by scores based on clinical and angiographic characteristics.

Tratamento percutâneo de pseudoaneurismas por injeção de trombina guiada por ultrassom / Percutaneous treatment of pseudoaneurysms by ultrasound-guide thrombin injection

Pseudoaneurisma iatrogênico ocorre em 0,5% a 2% dos procedimentos percutâneos diagnósticos e em até 7% a 8% dos procedimentos percutâneos terapêuticos. A oclusão do pseudoaneurisma pela injeção de trombina guiada por ultrassom diretamente no interior do saco aneurismático é técnica pouco invasiva, de execução rápida e segura, e com alto índice de sucesso. A proposta deste trabalho é relatar nossa experiência no tratamento do pseudoaneurisma iatrogênico por injeção de trombina guiada por ultrassom. Método: Entre setembro de 2006 e fevereiro de 2010 realizamos 1.811 procedimentos cardíacos percutâneos com ocorrência de 15 pseudoaneurismas (0,8%), dos quais 13 foram tratados com injeção de trombina guiada por ultrassom de forma consecutiva. Características clínicas, tipo de procedimento, medicações coadjuvantes, tamanho e morfologia dos pseudoaneurismas, dose de trombina utilizada, resultado da terapia e ocorrência de complicações foram documentados e armazenados prospectivamente em banco de dados e, então, analisados retrospectivamente. Resultados: A taxa de sucesso primário foi de 100%, com apenas uma recidiva sete dias após a abordagem inicial, tratada com sucesso pela mesma técnica. Não foi observada ocorrência de complicações relacionadas à injeção de trombina guiada por ultrassom e todos os pacientes apresentavam-se assintomáticos aos 30 dias de acompanhamento. Conclusão: A injeção de trombina guiada por ultrassom realizada por profissionais com experiência em ultrassom vascular e em punções transparietais de cistos e coleções é uma opção terapêutica viável, prática e segura no tratamento do pseudoaneurisma iatrogênico.

Background: Iatrogenic pseudoaneurysm is observed in 0.5% to 2% of diagnostic percutaneous procedures and in up to 7% to 8% of therapeutic percutaneous procedures.Pseudoaneurysm occlusion by ultrasound-guided thrombin injection directly in the aneurysm sac is a minimally invasive, quick and safe procedure with a high success rate. The aim of our study is to report our initial experience in treatment of iatrogenic pseudoaneurysms by ultrasound-guidedthrombin injection. Method: Between September 2006 and February 2010, 1,811 percutaneous coronary interventions were carried out with an occurrence of 15 pseudoaneurysms(0.8%), of which 13 were consecutively treated by ultrasound-guided thrombin injection. Clinical characteristics, type of percutaneous procedure, adjuvant therapy, size and morphology of pseudoaneurysms, thrombin dose, success and complication rate were prospectively documented and later retrospectively analyzed. Results: Primary success rate was 100% with just one recurrence seven days after the initial approach, which was successfully treated using the same technique. There were no complicationsrelated to the ultrasound-guided thrombin injection and all of the patients were asymptomatic 30 days after the procedure. Conclusion: Ultrasound-guided thrombin injectionperformed by professionals experienced in intravascular ultrasound and transparietal punctures of cysts and collections is a feasible, practical and safe option in the treatment of iatrogenic pseudoaneurysms.

Angioplastia "primária" de artéria carótida interna direita em paciente com contraindicação à terapia trombolítica / Primary angioplasty of right internal carotid artery in patients with contraindications to thrombolytic therapy

É relatado o caso de paciente do sexo masculino, de 63 anos de idade, que apresentava história prévia de acidente vascular encefálico isquêmico, com sequela motora e oclusão da artéria carótida interna esquerda. O paciente foi admitido no serviço de emergência com episódio agudo (quatro horas após o início dos sintoma) de novo evento isquêmico cerebrovascular. Apresentava contraindicação absoluta para ser submetida a terapia trombolítica, em decorrência da recente utilização de biópsia hepática. Assim, optou-se pela realização, na fase aguda, de angiografia de artéria carótidas e vetebrais. A lesão culpada foi identificada e procedeu-se ao implante de stent autoexpansível, obtendo-se sucesso angiográfico e melhora clínica substancial. Embora não exista substrato robusto na literatura que suporte a conduta adotada (angioplastia "primária" da artéria carótida intena), essa pareceu ser a melhor estratégia a ser implementada naquele momento.

We report a case of a 63-year-old male patient with a previous history of ischemic stroke, motor sequelae and occlusion of the left internal carotid artery. He was admitted at the emergency room with an acute episode of a new ischemic stroke (4 hours after symptoms onset). The patient had an absolute contraindication for thrombolytic therapy due to a recent liver biopsy. Thus, we decided to perform an emergency angiography of the carotid and vertebral arteries. Culprit lesion was identified and we decided to implant a self-expandable stent, obtaining angiographic success and significant clinical improvement. Although we do not have strong evidence supporting the chosen strategy ("primary" angioplasty of the internal carotid artery), it seemed to be the best one to be used at the time.